British Journal of Urology (1998), 82, 196–198
REVIEW
Urinary bladder wall repair: what suture to use?
K.M .I. PAL
Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
Introduction
At present there are no clear guidelines as to the most
suitable suture material available for the closure of
urinary bladder wall defects; the general tendency is to
use one of the synthetic absorbable suture materials.
The interior of the urinary bladder is encountered often
by any surgeon opening the abdomen routinely. The
fluid nature of its contents, with a high concentration
of solutes, predisposes to both a susceptibility to infection
and a propensity to form concretions, especially on
foreign bodies.
It is now accepted practice that only absorbable suture
material should be used to repair bladder wall defects,
although initial experimental evidence had suggested
that polypropylene (a monofilament nonabsorbable
suture) could be used in urological procedures [1–4]. Of
the absorbable sutures, the earliest available and most
frequently used until recently was chromic catgut. With
the introduction of a variety of synthetic absorbable
sutures, much attention has been given to their use in
bladder surgery.
At present there is no simple answer to the choice of
which suture is best suited for bladder repair. An ideal
suture should have good handling and knot-holding
properties, should induce no tissue reaction and be
absorbable, but maintain its strength long enough for
sound healing to take place. In addition, for the urinary
bladder it should not be aCected by urinary constituents
or by infected urine, and should not be lithogenic. In
practice, the issue of cost must also be addressed in this
definition, for cost is increasingly important in providing
quality medical care. Indeed, currently it must be shown
that there is an objective clinical advantage of one
treatment methodology over another, rather than a
perceived theoretical superiority.
Types of absorbable sutures
Absorbable sutures are made from either collagen
(catgut) or synthetic polymers. In the former, the tensile
Accepted for publication 12 February 1998
196
strength is decreased and they are absorbed in tissues
through degradation by acid hydrolytic and collageno-
lytic enzymes. To improve their tensile strength and
resistance to enzymatic digestion, the material is treated
with aldehyde solution and chromium trioxide, produc-
ing ‘chromic’ catgut. Despite rigorous quality control,
these sutures tend to have a variable loss of tensile
strength and absorption time.
The synthetic absorbable sutures most commonly used
at present are derived from a-polyesters. The polymers
used for their construction are inherently rigid and thus
can be used as monofilaments only in the finest gauge.
For clinical use, the fine filaments have to be braided to
produce diCerent suture sizes. The first to be introduced
was polyglycolic acid (PGA, Dexon@), which was fol-
lowed by polyglactin 910 (Vicryl@). Monofilament
absorbable suture such as polydioxanone (PD) has also
been developed. Synthetic absorbable sutures appear to
be chemically degraded by the nonenzymatic hydrolysis
of ester bonds; their loss of tensile strength and physical
structure in tissues is more uniform and can be predicted
more accurately.
Sutures used in bladder repair
To define the best suture material for bladder repair, the
following areas were examined: (i) tissue/material inter-
action; (ii) gain in tissue strength through healing in
relation to the loss of tensile strength in the suture
material with time; (iii) changes in suture tensile strength
with time; (iv) changes in suture tensile strength on
contact with uninfected and infected urine; (v) the
lithogenic potential of diCerent materials. Unfortunately
most of the answers available relate to either laboratory
conditions or animal models; whether results from these
sources can be extrapolated to clinical settings in their
entirety is open to question.
The inflammatory response to suture materials has
been of concern in all types of tissues. It is thought that
the more intense the inflammatory response, the slower
the gain in wound strength because of the greater local
degradation of collagen. Catgut sutures have been shown
to cause the greatest inflammatory response in several
© 1998 British Journal of Urology

tissues [5]. Studies have compared tissue inflammatory
response in the urinary bladder, for diCerent suture
types, in animal models. In rabbits, on microscopic
examination there was no diCerence in the inflammatory
reaction between 5/0 catgut, 5/0 PD and polypropylene
[6]. In rats, PD had the greatest inflammatory response
initially, although catgut, PD and polyglactin had a
similar response at 6 months [7]. The clinical significance
of moderate diCerences in inflammatory response at the
microscopic level is debatable.
The urinary bladder is one of the weakest organs
where unwounded wall strength is concerned, compar-
able with the colon [8]. On healing, it behaves diCerently
to other tissues, having a very rapid gain in wound
strength after approximation of the edges. The force
needed for tissue disruption approaches that of
unwounded tissue 14–21 days after wounding in animal
models [8].
An argument proposed for the use of synthetic
absorbable sutures is the extended tissue support pro-
vided, for up to 3–4 weeks. Tissues with comparable
tensile strength, e.g. colon and stomach, attain 50–70%
of normal tissue strength 120 days after the surgical
closure of wall defects [8,9]. Unwounded tissues appar-
ently have an inherent strength many times more than
that needed for the normal physical stress of their
particular function, thus the argument about longer
support loses its force. Barham et al. [10] have shown
that only in irradiated bladder tissue is the healing
wound strength statistically better with the use of syn-
thetic absorbable sutures.
The loss of suture tensile strength with time is an
important and often reported issue; absorbable sutures
lose tensile strength predictably in tissues with time,
more so than the synthetic variety. The tissue disruption
force for normal bladder is #400 g/cm [8]. The suture
breaking-strengths of 2/0 and 3/0 sutures, i.e. those
commonly used in bladder repair, are given in Table 1
[11–13]. These sutures all have breaking strengths
many times the force required for disruption in normal
tissues. Sutures lose # 40% of their original strength on
forming a secure knot, the latter being the weakest part
[14]. After 2 weeks, all three types of absorbable suture
Table 1 Tensile strength (g) of standard dry sutures [11,12] and
15 days after implantation in the subcutaneous tissues of rabbit [13]
Size (dry) Size (implanted)
Suture type 3/0 2/0 3/0 2/0
Chromic catgut 3000 4454 272 545
Polyglycolic acid 2772 4363 977 909
Polyglactin 910 NA 5331 NA 3245
© 1998 British Journal of Urology 82, 196–198
UR INARY B LADDE R WALL REPAI R 197
retained significant strength; bladder wall wound
strength is then >80% of the normal unwounded
wall [8].
The ability of various suture materials to maintain
their strength while exposed to sterile and infected urine
has been examined [15]. In sterile urine, PD lost its
strength and became fragmented after 3–6 days; PGA
gradually lost strength, losing 74% of its original strength
by 10 days. Catgut showed little change in its breaking
strength over the 10-day period. In acidic urine infected
with Escherichia coli PD lost all its strength after 6–10
days; PGA lost 72% of its original strength after 10 days.
Conversely, catgut had lost only 8% of its original
breaking value. In alkaline urine infected with Proteus
spp, PD sutures disintegrated over 3 days; PGA sutures
reacted similarly, with sutures completely dissolving by
the second day. However, catgut showed a rise in
breaking strength during the first 24 h and had only
lost 6% of its original strength after 10 days.
Studies on the lithogenic properties of various suture
materials have shown that lithogenesis is proportional
to the duration of absorption of the material. The highest
incidence has been noted with nonabsorbable braided
suture material; monofilament nonabsorbable sutures
have similar problems, confirmed in experimental and
clinical settings [2,3,8]. The use of both these types has
been discontinued for bladder repair.
One of the major disadvantages of animal-based stud-
ies has been the species-specific diCerences in lithogenic
potential for diCerent sutures [2]. In the rabbit, with
alkaline urine and very high susceptibility to stone
formation in experimental settings, the lowest incidence
of concretion was with chromic catgut, the highest with
polypropylene and intermediate with PD [6]. In another
study conducted in the rat [7] the lithogenic potential
of all three materials was similar, although the urine
was never alkaline. In dogs, none of the sutures tested
led to stone formation [2].
Conclusion
Of the absorbable sutures, chromic catgut has been used
the longest and has stood the test of time. The synthetic
absorbable sutures have some theoretical advantages
but there have been no studies on humans to date where
these advantages have been shown to be clinically
significant. Laboratory experiments and studies on ani-
mals have given conflicting results and can be interpreted
either way, depending on personal bias. As to rec-
ommending which suture to use in repair of the urinary
bladder, it can be safely stated that currently there is no
suture material that has been convincingly shown to be
better than chromic catgut in clinical trials. If no clinical
advantage can be shown, then cost is increasingly
198 K. M.I . PAL
significant. There is a considerable diCerence in the price
of diCerent absorbable sutures: chromic catgut, polyglac-
tin 910 and PD cost (per 12, in rupees) 225, 1200 and
2500, respectively, i.e. the polyglactin and PD cost 4.9
and 10 times the catgut (prices from Ethicon Ltd,
Pakistan). Thus, after reviewing the available evidence
it reasonably certain that there is no convincing evidence
for discontinuing the use of chromic gut in the repair of
the urinary bladder.
References
1 Bartone FF, Stinson W. Reaction of the urinary tract to
polypropylene sutures. Invest Urol 1976; 14: 44–6
2 Kaminske JM, Katz AR, Woodward SC. Urinary bladder
calculus formation on sutures in rabbits cats and dogs.
Surg Gyn Obs 1978; 146: 353–7
3 Healey GB, Warren MM. Stone formation on polypropylene
suture. J Urol 1979; 121: 836–7
4 Yudofsky SC, Scott FB. Urolithiasis on suture materials: its
importance, pathogenesis and prophylaxis: an introduction
to the monofilament Teflon suture. J Urol 1969; 102:
745–9
5 Van Winkle W, Hastings JC. Considerations in the choice
of suture materials for various tissues. Surg Gyn Obs 1972;
135: 113–26
6 Morris MC, Baquero A, Redovan E, Mahoney E, Bannet
AD. Urolithiasis on absorbable and non-absorbable suture
materials in the rabbit bladder. J Urol 1986; 135: 602–3
7 Stewart DW, BuBngton PJ, Wachsman J. Suture material
in bladder surgery: a comparison of polydioxanone, polyg-
lactin, and chromic catgut. J Urol 1990; 143: 1261–3
8 Hastings JC, Van Winkle W Jr, Barker E, Hines D,
Nichols W. The eCect of suture materials on healing
wounds of the bladder. Surg Gyn Obs 1975; 140: 933–7
9 Hastings JC, Winkle WV, Barker E, Hines D, Nichols W.
ECect of suture materials on healing wounds of stomach
and colon. Surg Gyn Obs 1975; 140: 701–7
10 Barham RE, Butz GW, Ansell JS. Comparison of wound
strength in normal, radiated and infected tissues closed
with polyglycolic acid and chromic catgut sutures. Surg
Gyn Obs 1978; 146: 901–7
11 Katz AR, Turner RJ. Evaluation of tensile and absorption
properties of polyglycolic acid sutures. Surg Gyn Obs 1970;
131: 701–16
12 Howes EL. Strength studies of polyglycolic acid versus
catgut sutures of the same size. Surg Gyn Obs 1973;
137: 15–20
13 Craig PH, Williams JA, Davis KW et al. Biologic comparison
of polyglactin 910 and polyglycolic acid synthetic
absorbable sutures. Surg Gyn Obs 1975; 141: 1–10
14 Rodeheaver GT, Thacker JG, Owen J, Strauss M,
Masterson T, Edlich RF. Knotting and handling character-
istics of coated synthetic absorbable sutures. J Surg Res
1983; 35: 525–30
15 El-Mahrouky A, McElhaney J, Bartone FF, King L. In vitro
comparison of the properties of polydioxanone, polyglycolic
acid and catgut sutures in sterile and infected urine. J Urol
1987; 138: 913–5
Author
K.M.I. Pal, FRCS, MSc, Department of Surgery, Aga Khan
University Hospital, Stadium Rd, PO Box 3500, Karachi
74800, Pakistan.
© 1998 British Journal of Urology 82, 196–198